PHARMACISTS FOCUS ON HELPING PNEUMOCOCCAL VACCINES … · 2019. 9. 27. · of pneumococcal meningitis.4 VACCINES FOR THE PREVENTION OF PNEUMOCOCCAL DISEASE Two vaccines are currently

copy 2018 by the American Pharmacists Association All rights reserved

FOCUS ON PNEUMOCOCCAL VACCINES FOR ADULTS PHARMACISTS HELPING PROTECT PATIENTS AND COMMUNITIES FROM PNEUMOCOCCAL DISEASE

FOCUS ONPNEUMOCOCCAL VACCINES FOR ADULTS

PNEUMOCOCCAL DISEASE A CAUSE OF SERIOUS ILLNESSPneumococcal disease is a significant contributor to illness in adults and children it is caused by Streptococcus pneumoniae a gram-positive bacterium that colonizes the nasopharynx of up to 90 of healthy people1 Although carriers of S pneumoniae may be asymptomatic they can transmit the bacteria to others through airborne respiratory droplets or by direct contact with infected respiratory secretions

More than 90 serotypes of S pneumoniae have been known to cause serious disease including pneumonia bacteremia meningitis sinusitis and otitis media12 The 10 most common serotypes are estimated to account for approximately 62 of invasive disease worldwide1 According to the Centers for Disease Control and Prevention (CDC) an estimated 4 million illness episodes 445000 hospitalizations and 22000 deaths are attributed to pneumococcal disease annually in the United States2

Pneumococcal pneumonia is the most common infection resulting from S pneumoniae accounting for approximately one-third of community-acquired pneumonias1 In the United States approximately 400000 adults are hospitalized with pneumococcal pneumonia each year1

Pneumococcal bacteremia is a serious infection of the bloodstream that occurs in 25 to 30 of patients who have pneumococcal pneumonia1 While the symptoms of pneumococcal bacteremia are usually nonspecific (eg

fever chills difficulty breathing) it can lead to septicemia and cause death in 20 of patients (up to 60 of elderly patients)12

S pneumoniae causes over 50 of all cases of bacterial meningitis affecting an estimated 3000 to 6000 patients annually1 Pneumococcal meningitis is fatal in approximately 22 of adults13 Signs and symptoms of pneumococcal meningitis are similar to other bacterial causes of meningitis and may include headache lethargy irritability seizures vomiting cranial nerve involvement and coma Neurologic sequelae (eg focal neurological deficits hearing loss long-term cognitive deficits) are common in patients who survive a case of pneumococcal meningitis4

VACCINES FOR THE PREVENTION OF PNEUMOCOCCAL DISEASETwo vaccines are currently available for the prevention of disease caused by S pneumoniae One is a 13-valent pneumococcal conjugate vaccine (PCV13) and the other is a 23-valent pneumococcal polysaccharide vaccine (PPSV23)1

bull PCV13 (Prevnar 13mdashPfizer) bull PPSV23 (Pneumovax 23mdashMerck)

Who should receive the pneumococcal vaccines and when Both pneumococcal vaccines are recommended for all adults 65 years of age and older as well as some adults 19 to 64 years of age To view details and recommended vaccine schedules go to56 httpswwwcdcgovvaccineshcp

acip-recsvacc-specificpneumohtml and httpswwwcdcgovvaccinesscheduleshcpadulthtml The recommended uses of PCV13 and PPSV23 in adults are complicated and have undergone several changes in recent years Careful reading of the Advisory Committee on Immunization Practices (ACIP) immunization schedules and footnotes will help pharmacists determine the recommended uses of these vaccines in various patient populations6 Key ACIP recommendations are summarized in this brochureFor adults aged 65 years and olderbull Patients who have not previously

received pneumococcal vaccine should receive one dose of PCV13 followed 1 year later by one dose of PPSV23

bull Details for those who have previously received pneumococcal vaccine are shown in Figure 1

For adults 19 to 64 years of agebull Figure 2 shows risk groups of

patients that should receive pneumococcal vaccine(s) as well as the recommendations for the schedule for administering the vaccine(s)6

General tips for the use of pneumococcal vaccines in adults include the following67

bull All adults should receivemdash Only one dose of PCV13 with the

age for administration depending on the presence of various health conditions

mdash One to three doses of PPSV23 depending on age and health conditions

bull PCV13 and PPSV23 should not be administered concomitantly

bull When both PCV13 and PPSV23 are indicated PCV13 optimally should be administered first


PHARMACISTS HELPING PROTECT PATIENTS AND COMMUNITIES FROM PNEUMOCOCCAL DISEASE

This resource is designed to offer pharmacists a concise and accurate tool to support making recommendations for administering pneumococcal vaccines to appropriate adult patients

Information is included for addressing questions and concerns so that pharmacists are prepared to educate patients about the available vaccines



Figure 1 Recommendations for Routine Use of Pneumococcal Vaccine for Adults 65 Years of Age and Older

Adapted from Connecticut Immunization Coalition (httpcsmsorgwp-contentuploads20160116-CT-Flu-Algorithm-Yellow-Arrowspdf) and California Department of Public Health Immunization Branch (httpezizorgassetsdocsIMM-1152pdf) For further information see httpswwwcdcgovvaccinesvpdpneumohcpindexhtml

Figure 2 Recommendations for Pneumococcal Vaccination of Adults 19-64 Years of Age With High-Risk Conditions





bull The interval between PCV13 and PPSV23 in immunocompetent individuals should be at least 1 year if given after 65 years of agemdash Among adults with immunocompromising conditions

anatomical or functional asplenia cerebrospinal fluid leak or cochlear implant the interval should be at least 8 weeks

bull The interval between two doses of PPSV23 should be at least 5 years

RECOMMEND PNEUMOCOCCAL VACCINEPharmacists should have a system in place for identifying patients who are appropriate for pneumococcal vaccine administration and should recommend the vaccine(s) to them The assessment should utilize information obtained during patient intake as well as any information available from an Immunization Information System (IIS) or the patientrsquos primary care provider Examples of ways to prompt vaccine recommendations includebull Program the pharmacyrsquos electronic prescriptionhealth

record system to identify patients who are 65 years of age or older andor have medical conditions indicating a need for vaccination and trigger an alert if the patient has not previously been vaccinated The system could also provide prompts to contact the patient for subsequent doses

bull Include a review of vaccination needs during medication therapy management encounters and offer appropriate vaccinations or refer patients to other providers who can vaccinate if appropriate

bull Use patient education posters and other resources to increase patient knowledge of the disease its significance and availability of vaccines

bull Ascertain whether the patient smokes cigarettes and recommend PPSV23 along with tobacco cessation interventions for appropriate patients

bull Identify patients whose electronic prescriptionhealth records indicate that they are receiving treatment for one of the high-risk health conditions identified in Table 2 those patients could be targeted for educational interventions about the benefits of pneumococcal vaccines

bull Ensure that appropriate disease state management services (eg diabetes) have a systematic process in place to assess the need for pneumococcal vaccine and support the administration of appropriate immunizations

bull Utilize technicians and other support personnel and technology to obtain vaccination history make reminder phone calls to patients schedule follow-up visits and educate the public

Applying the Pneumococcal Vaccine Recommendations

Q Mrs Jones is 47 years old and was recently diagnosed with HIV Assuming she has not previously received any pneumococcal vaccines which pneumococcal vaccine(s) should she receive and when

A Both PCV13 and PPSV23 are indicated for Mrs Jones according to the following schedule

bull She should receive one dose of PCV13 now

bull Because she is immunocompromised she should receive PPSV23 8 weeks after the administration of PCV13

bull A second dose of PPSV23 should be administered 5 years after the first PPSV23 dose

bull A third dose of PPSV23 should be administered at age 65 years (at least 5 years after the second PPSV23 dose)

Of note Mrs Jones will not need PCV13 when she reaches 65 years of age because she will already have received a dose of this vaccine as an adult

Q Mr Vyas is 30 years old and smokes 1 pack of cigarettes per day The pharmacist recommends that he enroll in a tobacco cessation program but he remains resistant to change Which pneumococcal vaccine(s) should he receive and when

A Mr Vyas is an appropriate candidate for pneumococcal vaccination according to the following schedule

bull One dose of PPSV23 now

bull When he reaches 65 years of age he should receive one dose of PCV13

bull A second dose of PPSV23 should be administered at least 1 year after the PCV13 (at least 5 years after the first dose of PPSV23)



ANSWERING PATIENTSrsquo QUESTIONS ABOUT PNEUMOCOCCAL VACCINEAdult patients may be unaware that they are appropriate candidates for pneumococcal vaccine and may have questions Some potential questions and suggested answers include3

Why do I need this vaccine The CDC recommends pneumococcal vaccine for individuals who are at high risk for developing pneumococcal disease and because of your age andor health condition you are considered high risk Receiving this vaccine can help prevent serious illness

Is pneumococcal disease really that badPneumococcal disease can cause serious illnessmdashincluding pneumococcal pneumonia meningitis and blood infectionmdashand death Recent estimates suggest that 22000 adults in the United States die from pneumococcal disease each year

How is pneumococcal disease spreadThe bacteria that cause pneumococcal disease are commonly found in the respiratory tract of healthy adults and are spread from person to person by respiratory droplets in the air or direct contact with infected respiratory secretions Good hygiene such as regular hand washing and coughing into your elbow rather than your hand can help reduce transmission

I already had a pneumococcal vaccine Why do I need one againThere are two different types of pneumococcal vaccines that protect against different types of bacteria that cause pneumococcal disease The recommendations for the use of these vaccines vary based on your age and health conditions For example if you are 65 years or older you

should have one dose of each vaccine If you are between the ages of 19 and 64 years and have certain health conditions you may need one dose of PCV13 and one or two doses of PPSV23 before you turn 65 years oldThe maximum number of PPSV23 doses recommended in a lifetime is three doses which includes up to two doses before 65 years of age for certain high-risk people plus one dose for everyone 65 years of age and older

Can I get both vaccines at the same timeNo The administration of the two vaccines should be separated by a minimum of 8 weeks In some cases you should wait at least 1 year between both vaccines

I might be pregnant Is it safe to get this vaccineBoth vaccines may be administered to women who are pregnant The safety of PPSV23 for pregnant women has not been studied although no negative effects have been reported among newborns whose mothers were inadvertently vaccinated during pregnancy Women who are at high risk of pneumococcal disease and who are candidates for pneumococcal vaccine should be vaccinated before pregnancy if possible ACIP has not published pregnancy recommendations for PCV13 at this time The use of PCV13 is limited among women of childbearing age8

Who shouldnrsquot receive the pneumococcal vaccineIf you have previously had a severe allergic reaction to the vaccine or one of its components you should not receive the vaccine If you currently have a moderate to severe acute illness you should wait to receive the vaccine until after your condition improves

If the vaccines are administered to children why do adults need to receive them tooOne of the pneumococcal vaccines PCV13 is indicated for all children and the other PPSV23 is given to children with certain health conditions However these vaccines are relatively new and therefore most adults today did not receive these vaccines when they were children Current CDC recommendations include vaccinating children and adults

I canrsquot remember if Irsquove had this the pneumococcal vaccine What should I doWe can look in the statersquos Immunization Information System (IIS) and check with your primary care provider to see whether you have a record of receiving this vaccine However if we cannot locate your records you should receive the recommended vaccine because extra doses will not harm you

Irsquove already had pneumococcal disease and it was confirmed by a lab test Do I still need the vaccineYes There are many types of bacteria that cause pneumococcal disease and infection with one of them does not provide protection against the others One of the vaccines protects against 23 subtypes and the second protects against 13 subtypes




DISCLAIMERAPhA does not assume any liability for how pharmacists or other health care professionals use this resource In all cases licensed health care professionals must use clinical judgment to ensure patient safety and optimal outcomes related to pneumococcal immunization

Developed bySupported by

ADMINISTER OR REFER AND DOCUMENT PNEUMOCOCCAL VACCINATIONWhen administering pneumococcal vaccine (as well as any other vaccine) documentation regarding vaccine administration and communication with other members of the health care team is essential for providing collaborative care that ensures all the patientrsquos immunization needs are met Be sure to

1 Give the patient the current Vaccine Information Statement (VIS) for the vaccine that will be administered

2 Answer any questions the patient may have and discuss expectations with the patient

3 If the patient is willing to be vaccinated and you do not administer the vaccine provide a referral (written or electronic) to a provider who will

4 Maintain a permanent record of the immunization a Date the vaccine was administered

b Manufacturer of vaccine and lot number c Anatomical site of administration and dose d Date of VIS and date provided to patient e Name address and title of the person administering

the vaccine5 Provide the patient with an updated immunization record

card6 Report immunization to the state or local Immunization

Information System7 Send notification of the vaccination to the patientrsquos

primary care provider if known and inform the provider that the vaccination will be submitted to the statersquos Immunization Information System and the patientrsquos health insurance if applicable

8 Report adverse events to the Vaccine Adverse Event Reporting System (VAERS) (httpsvaershhsgov) and the patientrsquos primary care provider

9 If a follow-up vaccination is needed inform the patient schedule the vaccination andor insert the reminder need within the pharmacyrsquos reminder-recall system

ACKNOWLEDGMENTS APhA gratefully acknowledges the financial support from Merck for the development of this resource

The following individuals served as content and pharmacy immunization practice advisors

Miranda Wilhelm PharmD Clinical Associate ProfessorSouthern Illinois University Edwardsville School of Pharmacy

Jessica L Kerr PharmD CDE Professor Southern Illinois University Edwardsville School of Pharmacy

ONLINE RESOURCESCDC Advisory Committee on Immunization Practices wwwcdcgovvaccinesacip

CDC General Best Practice Guidelines for Immunizationwwwcdcgovvaccinesedgeneral-recsindexhtml

Immunization Action Coalition wwwimmunizeorg

Infectious Diseases Society of America Guideline for Vaccination of Immunocompromised PatientswwwidsocietyorgGuidelinesPatient_CareIDSA_Practice_GuidelinesVaccination_of_the_Immunocompromised_Host

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REFERENCES1 Centers for Disease Control and Prevention Hamborsky

J Kroger A Wolf C eds Epidemiology and Prevention of Vaccine-Preventable Diseases 13th ed Washington DC Public Health Foundation 2015

2 Centers for Disease Control and Prevention Manual for the Surveillance of Vaccine-Preventable Diseases 5th and 6th ed Atlanta GA Centers for Disease Control and Prevention 2012 and 2013 Available at httpswwwcdcgovvaccinespubssurv-manualchpt11-pneumohtml Accessed June 13 2018

3 Immunization Action Coalition Pneumococcus Questions and Answers March 2016 Available at httpwwwimmunizeorgcatgdp4213pdf Accessed June 13 2018

4 Lucas MJ Brouwer MC van de Beek D Neurological sequelae of bacterial meningitis J Infect 201673(1)18-27

5 Centers for Disease Control and Prevention Pneumococcal ACIP Vaccine Recommendations Available at httpswww

cdcgovvaccineshcpacip-recsvacc-specificpneumohtml Accessed June 22 2018

6 Centers for Disease Control and Prevention Recommended immunization schedule for adults aged 19 years or older United States 2018 Available at httpswwwcdcgovvaccinesscheduleshcpadulthtml Accessed June 13 2018

7 Kobayashi M Bennett NM Gierke R et al Intervals between PCV13 and PPSV23 vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Morb Mortal Wkly Rep 201564(34)944-7

8 Centers for Disease Control and Prevention Immunization You Call the Shots Pneumococcal Contraindications and Precautions to Vaccination Available at httpswww2cdcgovnipisdYCTSmod1coursespneumo10415aspstudent_id=] Accessed June 22 2018



Figure 1 Recommendations for Routine Use of Pneumococcal Vaccine for Adults 65 Years of Age and Older


Figure 2 Recommendations for Pneumococcal Vaccination of Adults 19-64 Years of Age With High-Risk Conditions




































































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Documents

PHARMACISTS FOCUS ON HELPING PNEUMOCOCCAL VACCINES … · 2019. 9. 27. · of pneumococcal meningitis.4 VACCINES FOR THE PREVENTION OF PNEUMOCOCCAL DISEASE Two vaccines are currently